Psychology of Medicine

Saturday, May 19, 2018

Two years ago, I spent a week in Houston helping my stepbrother while he underwent treatment for Stage 4 lymphoma at the University of Texas MD Anderson Cancer Center. I sat with him while a nurse cleaned his chemo port and made records of her work, to keep his medical team updated. I accompanied him for the blood tests that determined his readiness for the next treatment. I stayed by his bed as his stem cells were harvested for a transplant, one of the cutting-edge, evidence-based therapies that ultimately saved his life.

Around the same time, I was helping my 22-year-old daughter, who struggled with alcohol and drug addiction. The contrast between the two experiences was stark. While my stepbrother received a doctor's diagnosis, underwent a clearly defined treatment protocol and had his expenses covered by insurance, there was no road map for my daughter. She had gone undiagnosed for several years, despite my reaching out to her health care providers, who either minimized my concerns or weren't sure what to do.

I had to hire an expensive interventionist — a professional who helps families find appropriate care and runs interventions — to find names of treatment centers. I spent weeks calling programs, asking questions and waiting to learn what insurance would cover. Finally, after my daughter agreed to treatment and we paid all costs up front, I sent her to a 45-day Arizona inpatient program, praying it would work.

Addiction, like cancer, is a complex disease that requires a multipronged approach. It also affects 1.5 times as many people as those with all cancers combined, and it was pivotal in causing some 64,000 overdose deaths in 2016 alone. It makes no sense that what is fast becoming our greatest health care crisis is still dealt with mostly outside the mainstream medical system.

According to a 2016 surgeon general's report, 10 percent of the 21 million Americans with substance-use disorders will receive treatment. This is in part because there are no national standards of care for treating addiction, and the $35 billion rehab industry is regulated piecemeal, state by state. While many treatment programs offer excellent care, others are motivated by profit and engage in practices such as patient brokering (in which hefty sums are paid to those who refer an addict to a program) and charging insurers exorbitant fees.

Friday, May 18, 2018

The first medicine designed to prevent migraines was approved by the Food and Drug Administration on Thursday, ushering in what many experts believe will be a new era in treatment for people who suffer the most severe form of these headaches.

The drug, Aimovig, made by Amgen and Novartis, is a monthly injection with a device similar to an insulin pen. The list price will be $6,900 a year, and Amgen said the drug will be available to patients within a week.

Aimovig blocks a protein fragment, CGRP, that instigates and perpetuates migraines. Three other companies — Lilly, Teva and Alder — have similar medicines in the final stages of study or awaiting F.D.A. approval.

"The drugs will have a huge impact," said Dr. Amaal Starling, a neurologist and migraine specialist at the Mayo Clinic in Phoenix. "This is really an amazing time for my patient population and for general neurologists treating patients with migraine."

Millions of people experience severe migraines so often that they are disabled and in despair. These drugs do not prevent all migraine attacks, but can make them less severe and can reduce their frequency by 50 percent or more.

As a recent editorial in the journal JAMA put it, they are "progress, but not a panacea."

Thursday, May 17, 2018

Depression runs in families, we know. But it is only very recently, and after considerable controversy and frustration, that we are beginning to know how and why. The major scientific discoveries reported last week by the Psychiatric Genomics Consortium in Nature Genetics are a hard-won breakthrough in our understanding of this very common and potentially disabling disorder.

If your parents have been depressed, the chances that you have been or will be depressed are significantly increased. The background risk of depression in the general population is about one in four – each of us has a 25% chance of becoming depressed at some point in our lives. And if your parents have been depressed, your risk jumps by a factor of three.

However, controversy has long swirled around the question of nature or nurture. Is the depressed son of a depressed mother the victim of her inadequate parenting and the emotionally chilly, unloving environment she provided during the early years of his life? Or is he depressed because he inherited her depressive genes that biologically determined his emotional fate, regardless of her parenting skills? Is it nature or nurture, genetics or environment, which explain why depression runs in families?

In the 20th century, psychiatrists ingeniously teased out some answers to these questions. For example, it was found that pairs of identical twins, with 100% identical DNA, were more likely to have similar experiences of depression than were pairs of non-identical twins, with 50% identical DNA. This indicated clearly that depression is genetically heritable. But well into the 21st century, the precise identity of the "genes for depression" remained obscure. Since 2000, there has been a sustained international research effort to discover these genes, but the field has been bedevilled by false dawns and inconsistent results.

That is why the study published last week is such a significant milestone. For the first time, scientists around the world, with leading contributions from the UK's world-class centres of psychiatric genetics research largely funded by the Medical Research Council at the University of Cardiff University, University of Edinburgh University and King's College London, have been able to combine DNA data on a large enough sample to pinpoint which locations on the genome are associated with an increased risk of depression. So we now know, with a high degree of confidence, something important about depression that we didn't know this time last year. We know that there are at least 44 genes, out of the 20,000 genes comprising the human genome, which contribute to the transmission of risk for depression from one generation to the next.

My first psilocybin journey began around an altar in the middle of a second-story loft in a suburb of a small city on the Eastern Seaboard. On this adventure I would have a guide, a therapist who, like an unknown number of other therapists administering psychedelics in America today, must work underground because these drugs are illegal. Seated across the altar from me, Mary (who asked that I use a nickname because of the work she does) began by reciting, with her eyes closed, a long and elaborate prayer derived from various Native American traditions. My eyes were closed, too, but now and again I couldn't resist peeking out for a glance at my guide: a woman in her 60s with long blond hair parted in the middle and high cheekbones that I mention only because they would, in a few hours, figure in her miraculous transformation into a Mexican Indian.

I also stole a few glances at the scene: the squash-colored loft with its potted plants and symbols of fertility and female power; the embroidered purple fabric from Peru that covered the altar; and the collection of items arrayed across it, including an amethyst in the shape of a heart, a purple crystal holding a candle, a bowl containing a few squares of dark chocolate, the personal "sacred item" that Mary had asked me to bring (a little bronze Buddha a friend brought me from Tibet) and, set squarely before me, an antique plate holding the biggest psilocybin mushroom I had ever seen.

There are times when the diagnosis announces itself as the patient walks in, because the body is, among other things, a text. I'm thinking of the icy hand, coarse dry skin, hoarse voice, puffy face, sluggish demeanor and hourglass swelling in the neck — signs of a thyroid that's running out of gas. This afternoon the person before me in my office isn't a patient but a young physician; still, the clinical gaze doesn't turn off, and I diagnose existential despair.

Let's not call this intuition — an unfashionable term in our algorithmic world, although there is more to intuition than you think (or less than you think), because it is a subconscious application of a heuristic that can be surprisingly accurate. This physician, whose gender I withhold in the interest of anonymity and because the disease is gender-neutral, is burned out in what should be the honeymoon of a career. Over the years, I have come to recognize discrete passages in a medical life, not unlike in Shakespeare's "Seven Ages of Man" — we have our med-school equivalent of "the whining schoolboy with his satchel and shining morning face" and the associate professor "jealous in honor, sudden and quick in quarrel." But what I see in my colleague is disillusionment, and it has come too early, and I am seeing too much of it.

In October 2014, my father was startled to receive a letter announcing the retirement, in a month's time, of our family physician. Both he and his doctor were in their late 60s by then, and their relationship went back about 30 years, to the early 1980s, after my father followed his father and paternal grandparents, all from the Midwest, to Southwest Florida. How they began seeing the doctor is beyond memory, but as my father's grandparents grew increasingly frail, his father frequently drove them to their doctor for checkups. At one of them, in the mid-'80s, the doctor suggested that it might be less strenuous for my great-grandparents if he met them in the parking lot. From then until they died, he came downstairs from his seventh-floor office with his black bag and climbed into the back seat of their yellow Oldsmobile 88 to give them their physicals.

More than a decade later, my grandfather, who was 78 by then and had chronic obstructive pulmonary disease, developed pneumonia. When he was admitted to the county hospital, it was the same doctor — now my doctor, too — who came to his room to describe his options: go on a ventilator and go home, where he would most likely remain bedridden for the remainder of his life (probably months), or let the illness run its course and die within a few days. My grandfather asked if the latter would hurt much. The doctor said no, he could make him comfortable. All right, then, my grandfather replied.

Monday, May 14, 2018

Ever since the American Hospital Association created its first Patient Bill of Rights in the early 1970s, medical centers, professional associations and states have been adapting it or creating their own. They are featured on websites and included in admissions packets, and adorn hospital walls.

But most of these documents are relics, responding to the concerns of a bygone era, like the right to "understandable information concerning diagnosis, treatment and prognosis" and to "a smoke-free environment." (Smoking has been forbidden in accredited hospitals for more than 25 years.)

If the cost of treatment is mentioned at all, it often squeaks in at the bottom. Consider how Johns Hopkins puts it: The patient has the right to "ask for an estimate of hospital charges before care is provided." Note: not to receive one.

Today patients' worries are financial as much as medical. Twenty percent of people with insurance say they have trouble paying their medical bills, a figure that rises to above 50 percent for the uninsured. In an era when patients are told to be better consumers of health care, they need a Financial Bill of Rights, too.

I knew, as soon as I heard the radiologist's voice on the phone, that the news wasn't good. "Is this an O.K. time to talk?" she asked. If everything was fine, she would have said that. Instead, she was saying, "I'm so sorry, but your biopsy came back positive for cancer."

Still in my pajamas, I scribbled down notes. "Will probably need lumpectomy and radiology. Find surgeon. Call this number." Of course, through the 10-minute conversation, the only word that really registered was "cancer."

What happened was this: A few months ago, I went for a mammogram. The doctors saw spots they didn't like. I wasn't concerned. Once you hit your late 40s, it's practically a rite of passage. You will see your mother's face when you look in the mirror. You will require a young child to fix your phone or explain a meme. And you, or a friend, or a sister, will get a call about her mammogram. Over the years, I've driven friends to get ultrasounds, and taken them home after needle biopsies. Everything always turned out fine, which reflects the statistics: Most women who have an abnormality on their mammograms will be O.K.

During a recent evening on call in the hospital, I was asked to see an elderly woman with a failing kidney. She'd come in feeling weak and short of breath and had been admitted to the cardiology service because it seemed her heart wasn't working right. Among other tests, she had been scheduled for a heart-imaging procedure the following morning; her doctors were worried that the vessels in her heart might be dangerously narrowed. But then they discovered that one of her kidneys wasn't working, either. The ureter, a tube that drains urine from the kidney to the bladder, was blocked, and relieving the blockage would require minor surgery. This presented a dilemma. Her planned heart-imaging test would require contrast dye, which could only be given if her kidney function was restored—but surgery with a damaged heart was risky.

I went to the patient's room, where I found her sitting alone in a reclining chair by the window, hands folded in her lap under a blanket. She smiled faintly when I walked in, but the creasing of her face was the only movement I detected. She didn't look like someone who could bounce back from even a small misstep in care. The risks of surgery, and by extension the timing of it, would need to be considered carefully.

I called the anesthesiologist in charge of the operating room schedule to ask about availability. If the cardiology department cleared her for surgery, he said, he could fit her in the following morning. I then called the on-call cardiologist to ask whether it would be safe to proceed. He hesitated. "I'm just covering," he said. "I don't know her well enough to say one way or the other." He offered to pass on the question to her regular cardiologist.

Thursday, May 10, 2018

When I was a medical student, I often found myself in the hospital gift shop. The gift shop was an oasis for me, not only because of the expansive candy selection that palliated my sugar cravings, but also because I could see gift-givers in cross-section. Loved ones came in and out, buying balloons for newborns and flowers for their parents or children. One would buy a newspaper for her spouse to read; another doting husband would buy a scarf for his wife to hide the scar from her recent surgery. Through their gifts, they were not only showing their love, but also their hope and yearning for health, for success, for life.

I found myself in the gift shop again on the day of my patient's planned discharge to home hospice. She was an elderly woman with metastatic cancer. She had been admitted for nearly a month.

As a third-year student, I had followed the course of her care throughout my time on the service. Every morning for that month, I walked into her room to ask how she was doing. I had watched her reach the limits of medicine; her disease was incurable. Perhaps it was just an instinct ingrained in me from my Italian-Jewish family, but I knew I could not leave the gift shop empty-handed. I settled on a stuffed animal, a black puppy.

Gift-giving to physicians is a relatively common practice, albeit a controversial one. One study in the British Medical Journal found that 20 percent of physicians in Britain had received a gift in the previous month. The study was conducted from May to July and therefore did not include the holiday months, when gift-giving may be even more frequent. Some doctors believe that patient gifts may predispose them to favoritism; others are willing to accept small gifts of low monetary value.